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Zorluk: Çok zorPhysiological Adaptation

A practical nurse (PN) is collecting data on an older adult client who underwent a transurethral resection of the prostate (TURP) 12 hours ago and is receiving continuous bladder irrigation (CBI). Which of the following findings should the PN report to the registered nurse (RN) immediately? Select all that apply.

  1. A
    The client expresses a severe, persistent urge to urinate despite active clear drainage in the catheter tubing.
  2. The client becomes increasingly restless and repeatedly asks staff members where they are.Cevap
  3. C
    The client's urinary drainage bag contains several small, dark red blood clots amidst light pink fluid.
  4. The client's blood pressure is 174/98 mm Hg with a heart rate of 54 beats/min.Cevap
  5. The client reports a new, severe headache accompanied by an episode of emesis.Cevap

Cevap

The correct findings to report immediately are the client becoming increasingly restless and disoriented, the blood pressure of 174/98 mm Hg with a heart rate of 54 beats/min, and the new, severe headache accompanied by emesis.
The correct findings (restlessness/confusion, hypertension with bradycardia, and headache/emesis) are classic manifestations of TURP syndrome. This life-threatening complication occurs when the body absorbs a large volume of the irrigation fluid used during the procedure, leading to severe fluid volume overload and dilutional hyponatremia. The fluid overload causes hypertension and reflex bradycardia, while the acute hyponatremia causes cerebral edema, manifesting as restlessness, confusion, headache, and vomiting. These findings represent a failure of physiological adaptation and require immediate reporting to the RN for emergency medical intervention.

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1
Analyze the client's clinical context and current treatment.
The client is 12 hours post-TURP with continuous bladder irrigation (CBI).
Understanding the procedure helps anticipate specific complications, such as hemorrhage, bladder spasms, and TURP syndrome.
2
Evaluate each finding to distinguish expected postoperative occurrences from life-threatening complications.
Restlessness, hypertension with bradycardia, and headache with emesis are abnormal and indicate a systemic crisis. Bladder spasms and small blood clots are expected findings.
The PN must prioritize findings that threaten the client's airway, breathing, circulation, or neurological status.
3
Synthesize the abnormal findings to identify the underlying physiological adaptation failure.
The combination of neurological changes (restlessness, confusion, headache, emesis) and hemodynamic changes (hypertension, bradycardia) points to dilutional hyponatremia and fluid volume overload (TURP syndrome).
During a TURP, irrigation fluid can be rapidly absorbed into the venous system, causing severe fluid shifts and electrolyte imbalances that require immediate emergency intervention.

Anahtar Kavram

TURP syndrome (dilutional hyponatremia and fluid volume overload)
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Konular

Physiological Adaptation

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